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February 23, 1998

Ethical Considerations in Executing and Implementing Advance Directives

Arch Intern Med. 1998;158(4):321-324. doi:10.1001/archinte.158.4.321

IN THIS ISSUE of the ARCHIVES, Gross1 presents data about the current use of advance directives in clinical practice and makes a number of suggestions. Central to this article are a number of unexamined assumptions. Several of these seem worth examining: (1) prior to losing their ability to make decisions, patients should be able to express their wishes about treatment and express them in documents that in the future might be binding on physicians and other health care providers; (2) when it comes to treatment decisions about theoretical situations not actually faced by patients at the time these documents are executed, patients' wishes should remain stable over time and not be changed at the time the situation is actually faced; (3) patients should be encouraged to execute advance directives because it is assumed that executing advance directives is something that responsible persons ought to do; and, therefore, (4) if advance directives have not been executed prior to hospital admission, patients should be encouraged to execute such directives at that time. There is, of course, an a priori assumption: adult patients have a right (or a justified claim) to have the wishes they expressed while they still had the capacity to make decisions carried out once such a capacity has been lost. Let me be clear at the outset: I do not in the least question that a patient's prior clearly enunciated and properly informed wishes need to be respected. I have serious concerns about the way these directives tend to be executed and interpreted.

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